Whittemore, Ruth Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Villa:e, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFI1C OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered ��Q7
Town /
Dist. No.s I...County Village ! ... . ..
It}rO (If city, give street address)
Name of deceased ./ 7.
�/f Single, married, widowed, ` .
Sex C. • .olor... • or divorced (write h word)..S,y/ ate ofAktil. �t�.19. ...
Age 1p Years Months Days Birth .... -. o .
C:use of ath.,.� .. .. .... . . . . ... --... -
Certificate was signed by M.D.
Address • , . .. . , .. - , 'P Y,_-,..
Place of Bul is :emoval) ... ,.
(If body is to be t•. ly hold, fill a later)
Cemetery Date of Burlal.... .... 719. 01:1:
(If body is to be temporarily held, till in space later)
The Certificate of Death containing the above stated particulars, having been pr nted to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local R rd with the above stated Registered
Number, a on the basis yreorIREBY GRANT A PERMIT
er
(Na a)
the . .. o hold temporarily a the body.
(I •1 iker or person having barge oP se) re ,00,or o rwise ose o [s o j)
Dated. .. .. . ../19..6J (Signed)
Local Registrar
Th'. Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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